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SOAP Notes

Sample Medicine SOAP S:No SOB/CP overnight. 3 pillow orthopnea (improved from 4 at admission). Pt feels swelling in feet has improved but still has to elevate legs frequently. Pt walked halls s difficulty but did not tolerate steps. O:T98.6 Tm99.3 HR87 RR14 BP114/69-129/78 I/O1800cc/4500cc FSBS 178-223 PE: GEN A&O x 3, in NAD HEENT PERRL, EOMI CV RRR, S3 present, no m/r/g, 2+ PE to mild calf RESP CTAB x mild crackles @ bases, breathing symm c normal effort ABD s/nt/nd, NABS, no HSMeg, no palpable masses MS MAEW, 5/5 strength UE/LE NEURO CN II-XII intact, normal sensation to LT/pressure/temp, two-point discrimination intact, gait normal, patellar and brachiorad DTRs 2/4 PSYCH affect, mood congruent and appropriate Labs: CBC, BMP or CMP Imaging: XR, CT, Echo, etc. A/P: 68 yo WM c CHF, HTN and DMII admitted for edema and DOE 1. CHF previously class II but pt now symptomatic c mild exertion; echo scheduled today to eval EF/cardiac fxn; pt on appropriate CHF regimen at home; will continue aggressive diuresis c Lasix and consider addition of Digitalis at this time; cont low Na diet 2. HTN currently on Lasix, BB and ACEI c good control, cont home meds 3. DMII on glucophage at home c FSBS in 250-300 range; on SSI c FSBS 178-223 in house; will consult DM Ed to educate pt on diet/exercise as well as recommend more appropriate home regimen; cont Q6H FSBS.

Surgery SOAP S:If post-op, always ask about incisional pain, flatus, bowel movements, urination (if no foley), any nausea/vomiting, response to pain meds (# of times PCA was admin.), if eating, whether tolerating PO well, and activity/ambulation. O:Vitals: Tm, Tc, HR, RR, BP, PulseOx (if applies) [List UOP for last 24h in 8h intervals, ask your resident whether they like most recent shift first or last] Similar to I/O, record drain outputs for last 24h in 8h intervals. PE: (important to examine the following)

Lungs: clear to auscultation? CV: any new murmurs? ABD: bowel sounds? (esp. if post-op b/c BS is an important deciding factor in when to advance diet) Incision: clear, dry, and intact? (C/D/I). Good granulation? Ext: any edema? Labs/Studies/Imaging/Path: A/P: Brief statement of overall impression. Always include post-op day (Day of Surgery is POD#0; next day is POD#1). A/P similar to medicine SOAP. Plan should be to the point! Include pain control, diet, PT/OT, f/u. OBSTETRICS & GYNECOLOGY ** Here you will find as many helpful templates and samples as we could find to assist you on your OB/GYN rotation. OB SOAP S:In any pain? Feeling contractions? O:Vitals FHT baseline, long-term variability, accels, decels, variables (describe the decel or variable). TOCO q_min; level of Pit SVE dilation/effacement/station (done by the resident or attending; students write DEFERRED). A/P: Age, GPs @ # weeks in latent/active labor. 1. FWB reassuring. 2. MWB how is the mother doing? Does she need pain meds? Are pain meds helping her? 3. Labor cont pit if being used. Include any change in labor. 4. GBS status if positive then indicate antibiotic being given. Sample Post-Partum Progress Note for a Cesarean Section S:+ clears without nausea, + ambulate, +void, pain controlled on PO meds, lochia <menses O:99.2 98.5 86 18 135/94 [if Tmax >100, please note the time like 101.2@2030] CV: RRR Lungs: clear Abd: soft, appropriately tender ND+BS, FF @ umbilicus Ext: 1+ edema, no cords or tenderness A/P: 26 yo BF G4P3A1 POD#1 s/p elective R/LTCS [repeat low transverse c/section] @ 39 weeks: 1) Advance to regular diet this morning 2) RNI: vaccinate before d/c 3) Routine post-op care Blood type/ Rubella status/ breast or bottle feeding/ birth control

Sample Post-Partum Progress Note for a Vaginal Birth S:+diet +ambulate, +void, lochia <menses O:99.2 98.5 86 18 135/94 [if Tmax >100, please note the time like 101.2@2030] CV: RRR Lungs: clear ABD: soft, appropriately tender, FF @ umbilicus Ext: 1+ edema, no cords or tenderness A/P: 26 yo BF G4P3A1 PPD#1 s/p SVD [spontaneous vaginal delivery] at 29 3/7 weeks for severe pre-eclampsia 1) blood pressure adequately controlled without meds 2) baby intubated but stable in NNICU 3) lactation consult 4) routine PP care Blood type/ Rubella status / breast or bottle feeding / birth control method desired

To check on NNICU babies, call 2-2481 and ask to speak to the nurse taking care of baby ____. Tell them youre taking care of the mom and want to know how the babys doing before seeing mom. Dont expect a real detailed answer but this is a good thing to do on babys less than 30 weeks. Postpartum Prescriptions **You can write multiple prescriptions on one paper, just number them appropriately and make it clear. Almost everyone goes home with: Prenatal vitamins, sig: 1 tab po qd, #100, 3 refills Motrin, 800 mg tabs, sig: 1 tab po q 6h prn pain, #30, 1 refill Patients following C/S generally also go home with: Percocet 5/325, sig: 1-2 tabs po q4-6h prn severe pain #30 (thirty) [need to write out number on narcotics] Patients following PPBTL usually get: Percocet 5/325, sig; 1-2 tabs po q4-6h prn severe pain #12 (twelve) Patients with bad vaginal lacerations usually get: Epifoam/Proctofoam, sig: apply to perineum t.i.d. prn pain, 2 large tubes, 2 refills Patients with anemia get: FeSO4, 325 mg tabs, sig: 1 tab po b.i.d. (or qd) #60, one refill [give about 2 months worth] Colace, 100 mg tabs, sig: 1 tab po b.i.d., #60, one refill They usually will benefit from a stool softener.

GYN SOAP S:Ask about pain control (on IV or PO meds), fever, nausea, vomiting, diet (and if tolerating), flatus, voiding, CP, and SOB. O:Vitals and UOP (if not in computer be sure to ask nurse) GEN A&OX3. NAD. CV RRR. No m/r/g. LUNGS STAB. ABD Note +/- BS. Soft. ND. Appropriate tenderness. INCISION c/d/i. No erythema or drainage. [Remove bandage on POD #1 unless specifically told not to] EXT Note edema and +/- SCDs. Labs/Studies A/P: POD # s/p [procedure] for [what reason]. List how patient is doing. AFVSS. 1. FEN IVF, diet 2. GU d/c foley? 3. CV stable? 4. Pain change to PO meds? 5. Other medical problems and their tx 6. Path pending if not back yet. GYN D/C ** Fill out the appropriate D/C form and write out the prescriptions. This is good to do on POD #0 so that it is done for the residents. Admit Date: D/C Date: Procedure: Meds: in pts language; Pts usually leave with: Norco 10/325 mg 1 PO Q4H prn for pain; Disp: 30 (no refills) Motrin 600mg PO Q6H prn for pain; Disp: 30 (no refills) FeSO4 325mg PO BID; Disp: 60 (3 refills) Colace 100mg PO BID; Disp: 60 (3 refills) Stairs: as tolerated Lifting: No more than 10-15# for 2-6wks Diet: No restrictions Driving: Not while taking pain meds (Norco) Other: Call if: temp >101, uncontrolled pain, severe nausea or vomiting, or any other concerns. In case of questions or emergency, call Dr. [Attending] at [phone #] or 911. "Blue border" paperwork takes the place of a dictated d/c summary on term (>=37 week) vaginal deliveries that are not induced and otherwise uncomplicated. Ask if you are unsure whether they meet this criteria. Other patients will need to be dictated so no blue borders will be necessary.

OB/GYN Pelvic Exam Charting Organ/Part Mons Vulva Perineum Feel/Observe For Female hair pattern, lice, lesions, growths Female appearance, edema, lesions, growths, discharge, clitoral adhesions, discoloration Growths, lesions, intactness (unrepaired lacerations, episiotomy breakdown) Tenderness, enlargement, discharge, urethral prolapse

Bartholins, Skeen's, Urethra Vagina Color, lesions, discharge, growths, tone Cervix Color, lesions, discharge, growths, appearance of os (split/round/open/closed), deviation from midline, consistency, size Size, shape, consistency, position, mobility, Uterus tenderness, deviation from midline, dextrorotation or levorotation Masses, enlargement, tenderness Adnexa Hemorrhoids, masses, strictures, fistulas Recto-Vaginal Commonly Used OB/GYN Abbreviations: Ab abortion (included elective,LOF loss of fluids (water therapeutic, and miscarriages)breaking) AFVSS afebrile vital signs stableLTCS low transverse C-section BSO bilateral salpingo-LTV long-term variability oophorectomyMAC conscious sedation C/D/I clean/dry/intactMWB maternal well-being CLE epiduralNSVD normal spontaneous C/S C-sectionvaginal delivery Ctx or Ucx contractionsPOBH past OB history FF fundus firmPP post partum FHT fetal heart tracingPGYNH past GYN history FM fetal movementPit pitocin FT full termPPBC post partum birth control FWB fetal well-beingPPROM preterm premature GETA general anesthesiarupture of membranes GPs Gravida (# of pregnancies)PROM premature rupture of & Para (# of births in the order:membranes Term, Preterm, Abortions, Living)TAH total abdominal IUP intrauterine pregnancyhysterectomy LFVD/OFVD forcep assistedTVH total vaginal hysterectomy vaginal deliveryTOCO tocometer (for Ctx) LMP last menstrual periodU/S - ultrasound

Pediatric SOAP S:What happened overnight per mom, per nurse, per pt. Eating (tolerating PO? Any emesis?), peeing, pooping. O:Vitals: Tmax for last 24h note other fever spikes (when) Tcurrent HR + 24h range RR + 24h range BP + SBP range/DBP range over 24 h O2 sat + 24h range Daily weight I/Os 24h total in (broken down by IV/PO) over 24h total out = total up or down in cc/kg in younger kids or Kcal/kg for babies on formula UOP Record as cc/kg/hr (>1 is nml) and stool output (<20 is nml). PE: At least GEN, HEENT, RESP, CV, ABD, EXT, NEURO Labs/Studies A/P: Briefly state overall impression. Then work up differential diagnosis. Break down plan by system. You may see PO ad lib in the FEN section.

PSYCHIATRY 1. Please check with your attending/resident regarding the preferred progress note format: either SOAP or CHEAP (Chief complaint, History, Exam, Assessment, and Plan). 2. Be aware that the following information that should be recorded in your SOAP/CHEAP notes: Note any change or lack of change in mental status. Note patients behavior. Note positive diagnostic studies. Summarize consultations. Note treatment plan with some justification of the treatment described. Note medications, dosages, and the effect or lack of effect. 3. Sign legibly with Your Name, MSIII and have your notes read and countersigned by your attending and/or resident. Discharge notes should include information about post-hospital plans and treatment follow-up. Psychiatric SOAP S: Events o/n. Use of PRN meds. O: Vitals (important in patients started on meds or with acute medical d/o). Record Sleep and Appetite. PE Pertinent. MSE

GEN appearance, race, dress, hygiene, behavior, eye contact, cooperativeness, alertness, orientation SPEECH rate (accelerated/slowed/normal), rhythm (halting/hesitancy/stuttering), volume (loud/soft/normal), lack of spontaneity? Hyperverbal? PSYCHOMOTOR psychomotor retardation or agitation, tremor, ataxia, wheelchair bound. MOOD in the pts words. AFFECT objective sense of pts mood: range (constricted/full/labile), intensity, mood congruent/incongruent? THOUGHT CONTENT passive or active SI, intent, plan, HI, A/VH, paranoia, delusions, obsessions and ruminations THOUGHT PROCESS linear, focused and goal oriented? Disorganized/scattered/logical/illogical/tangential/circumstantial? INSIGHT poor/fair/good/excellent JUDGMENT poor/fair/good/excellent. Is pt making good decisions for themselves and others in their care? IMPULSE CONTROL poor/fair/good/excellent MMSE mini mental Labs/Studies A: Brief statement of overall impression. Axis I: Primary psychiatric dx (major depressive d/o, somatization d/o, panic d/o, schizophrenia, bipolar d/o) Axis II: Personality d/o and mental retardation. (Dont dx a personality d/o for the first time in the hospital. It is not a dx that can be made in that setting. Instead, always write DEFERRED.) Axis III: Medical d/o Axis IV: Psychosocial stressors (chronic mental illness, financial or employment stressors, relationship strain) Axis V: Global Assessment of Functioning P: Med suggestions, suggestions for placement, suggestions for additional consults, f/u on outpatient treatment options.

Commonly Used Psych Abbreviations: ADL activities of daily livingHI homicidal ideation A/VH auditory or visualMR mental retardation hallucinationsNA narcotics anonymous Chem Dep chemicalSI suicidal ideation dependencySIGECAPS sx of depression: Sleep (Inc of Dec), InterestsDIGFAST sx of mania: Distractibility, Insomnia,(Dec), Guilt, Energy (Dec), Grandiosity, Flight of ideas,Concentration (Dec), Appetite (Inc or Dec), SpeechAppetite (Inc of Dec), (Pressured), ThoughtlessnessPsychomotor agitation, SI